Thesis Paul Ramler

Summary

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide. In this dissertation, we have focused on severe postpartum hemorrhage, and the main conclusions are as follows:

1) The incidence and treatment of severe postpartum hemorrhage in the Netherlands differs significantly form similar countries. We advocate continuous registration and evaluation of severe postpartum hemorrhage so that we can improve care for severe blood loss and work towards uniform evidence-based management guidelines.

2) The standard collection of ROTEM FIBTEM A5 (a rapid blood test to determine clotting problems) cannot be used as an early predictor of progression to severe blood loss after childbirth. More research is needed in which cases this test can be of added value during postpartum hemorrhage.

3) Randomized trial of the effectiveness of various interventions within postpartum hemorrhage is complicated by the unexpected and acute moment of occurrence of severe blood loss. Using a propensity score matched-cohort, we were able to compare two interventions in this way for the first time. This study design can be used for future comparative research on interventions when a randomized trial is not considered feasible.

4) Together with the Audit Committee Maternal Mortality and Morbidity of the Dutch Society of Obstetrics and Gynecology (NVOG), we evaluated all maternal mortality due to postpartum hemorrhage between 2006 and 2019 in the Netherlands. Our confidential audits of reported maternal mortality have led to multiple recommendations on how to improve care for such severe bleeding.